Chest Infections: Student/Resident Case Report Poster - Chest Infections I |

Focal Fibrosing Mediastinitis Resulting in Bi-Lobectomy in an 18-Year-Old Male FREE TO VIEW

Joshua Patterson, MD; David Graham, MD; Alan George, MD; Micah Will, MD; Deena Sutter, MD
Author and Funding Information

San Antonio Uniformed Services Health Education Consortium, San Antonio, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):170A. doi:10.1016/j.chest.2016.08.179
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Histoplasmosis can have a variety of presentations ranging from asymptomatic to acute pulmonary infection to chronic granulomatous disease. Fibrosing mediastinitis is an uncommon complication of histoplasmosis characterized by the proliferation of locally invasive fibrous tissue within the mediastinum.

CASE PRESENTATION: An 18-year-old male presented to clinic with shortness of breath. Examination revealed a well-appearing male with reduced air entry into the lower right hemithorax. CT scan confirmed a large right effusion and massive right hilar, mediastinal calcific lymphadenopathy. Bronchoscopy revealed extrinsic compression with complete obstruction of the RML bronchus. Endobronchial lymph node biopsy was negative for malignancy, sarcoidosis, and all cultures were negative. Secondary to the complex fluid collection and RML/RLL collapse from marked lymphadenopathy, surgery was suggested. Intraoperatively, dense adhesions and a thick inflammatory pleural rind covered the RLL. The hilar dissection planes were obliterated due to a large conglomerate of lymph nodes. RML/RLL bi-lobectomy was required given extent of disease. Histologic evaluation demonstrated areas of caseating necrosis with microcalcifications that were surrounded by fibrosis, which encompassed large hilar vessels and abutted the bronchus. A GMS stain highlighted thin-walled 3-5 µm yeast-like organisms within areas of necrosis.

DISCUSSION: The diagnosis of H. capsulatum infection can be made by culture, antigen or antibody detection, or direct examination of lung tissue. Histoplasmosis has been associated with chronic inflammatory complications including fibrosing mediastinitis. In our patient, the presentation was unique in regards to location of fibrosis. Though mediastinal fibrosis usually affects the superior mediastinum, fibrosis can also affect other mediastinal structures1. When localized to the hilum, the focal fibrosis may produce profound changes in the structure and function of the affected lung which can include obstruction and eventual obliteration of small airways. Histopathology and cytology remain the standard diagnostic approach for endemic mycoses2. Histologic examination may reveal distinct 2-5 µm, oval, narrow-based budding yeasts suggestive of H. capsulatum.

CONCLUSIONS: The diagnosis and etiology of mediastinal and hilar fibrosis is challenging because of its nonspecific clinical and radiologic presentation. Surgical biopsy and histopathologic investigation aid in this diagnostic dilemma. As in our patient, symptoms related to mediastinal and hilar fibrosis causing compression and obstruction to vital structures benefit from a multidisciplinary team approach.

Reference #1: Hammoud ZT, et al. Surgical management of pulmonary and mediastinal sequelae of histoplasmosis: a challenging spectrum. Annals of Thoracic Surgery. 2009; 88(2): 399-403.

Reference #2: Hage CA, et al. Pulmonary Histoplasmosis. Seminars in Respiratory and Critical Care Medicine. 2008; 29(2): 151-165.

DISCLOSURE: The following authors have nothing to disclose: Joshua Patterson, David Graham, Alan George, Micah Will, Deena Sutter

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543